Approach to patient with dysuria.

1. Dysuria
Sameer S. Sawaed

2. Definition:
• The sensation of pain, burning or
discomfort on urination.

3. Epidemiology
• In adulthood, more common in women
than men.
• Approximately 25% of women report
one episode of acute dysuria per year.
• Most common in women 25-54 years of
age and in those who are sexually
active.
• In men, dysuria becomes more
prevalent with increasing age.

4. Etiology
• Infectious:
- Most common cause
- Presents as; cystitis, urethritis,
pyelonephritis, vaginitis or prostatitis
• Non- infectious:
- Hormonal conditions (hypoestrogenism),
obstruction (BPH, urethral strictures),
neoplasms, allergic reactions, chemicals,
foreign body and trauma.

5. Differential Diagnosis of Dysuria
• UTI
• STD Chlamydia trachomatis , N. gonorrhea ,
and HSV all can cause urethritis and
symptoms of LUTI.
• Candidal infections
• Urethral or bladder irritation.
• Interstitial cystitis in young women.
• Bladder tumors
• Instrumentation
• Trauma
• BPH , prostatitis , epididymitis.
• Renal stones, renal infarction papillary
necrosis

6. Urinary Tract Infections
• UTI is Any infection involving the
urothelium, which includes urethral,
bladder, prostate and kidney infections.
• The term UTI and uncomplicated UTI
are often used to refer to cystitis

7. Epidemiology
• Urinary tract infection (UTI) is common
in women, in whom it usually occurs in
an anatomically normal urinary tract.
• The incidence of UTI is 50 000 per
million persons per year and accounts
for 1–2% of patients in primary care.

8. • Recurrent infection causes considerable
morbidity; if complicated, it can cause
severe renal disease including end-
stage renal failure. It is also a common
source of life-threatening Gram-
negative septicaemia.

9. Risk Factors
Sexual intercourse
Diaphragm contraceptive
Vaginal spermicide
Pregnancy
Menopause
Instrumentation
Urinary tract obstruction
DM
Immunosuppression
Malformation

10. Classification
• Upper urinary tract Infections:
- Pyelonephritis
• Lower urinary tract infections
- Cystitis (“traditional” UTI)
- Urethritis (often sexually-transmitted)
- Prostatitis

11. Presentation
• Frequency, urgency, dysuria, hematuria, supra-
pubic pain, grossly cloudy and malodorous
urine  THINK OF CYSTITIS
• High grade Fever, rigors (shaking chills),
nausea, vomiting, diarrhea, loin pain  THINK
OF ACUTE PYELONEPHRITIS
• Flu like symptoms low backache, few urinary
symptoms  THINK OF PROSTATITIS

12. Pathogenesis
• Infection is most often due to bacteria
from the patient’s own bowel flora
transferred to the urinary tract via the
ascending transurethral route
• May be via the bloodstream, the
lymphatics or by direct extension
(e.g.from a vesicocolic fistula).

13. Causative Agents
• Escherichia coli and other ‘coliforms’ –
80%
• Proteus mirabilis
• Klebsiella aerogenes
• Enterococcus faecalis
• Staphylococcus saprophyticus or
epidermidis – 5-15%

14. Lower Urinary Tract Infection
Cystitis
Uncomplicated (Simple) cystitis
In healthy woman, with no signs of
systemic disease
Complicated cystitis
In men, or woman with co-morbid
medical problems.
Recurrent cystitis

15. Uncomplicated
(simple) Cystitis
• Definition
Healthy adult woman (over age 12)
Non-pregnant
Rarely in men.
• Signs and symptoms
Dysuria
Frequency , urgency or both
No fever, nausea, vomiting, flank pain and no vaginal discharge
• Diagnosis
Dipstick urinalysis positive for nitrites or leukocyte esterase. (no culture or
lab tests needed)
• Prognosis :
Treatment is usually successful.
Symptoms of a bladder infection usually disappear within 24 - 48 hours
after treatment

16. Risk Factors and Treatment
• Major risk factor for uncomplicated simple
cystitis is sexual activity.
Treatment:
• Sulfamethoxazole-trimethoprim
• Amoxicillin
• Nitrofurantoin
• Ampicillin
• Ciprofloxacin
• Levofloxacin

17. Complicated Cystitis
• Females with comorbid medical
conditions
• All male patients
• Indwelling foley catheters
• Urosepsis/hospitalization

18. Diagnosis
• CBC + blood culture .
• Urine dipstick : pyuria on microscopic examination urine
WBC positive for nitrites or leukocyte esterase.
• Middle stream urine culture: bacterial account > 10^5/ml
• The following tests may be done to help rule out problems
in the urinary system that might lead to infection or make
a UTI harder to treat:
 CT scan of the abdomen
 Intravenous pyelogram (IVP)
 Kidney scan
 Kidney ultrasound
 Voiding cystourethrogram

19. Risk Factors and Treatment
Risk factors:
• Blockages in the urinary tract: Kidney stones or an enlarged
prostate can trap urine in the bladder and increase the risk of
urinary tract infection.
• Urinary tract abnormalities: that don't allow urine to leave the body
or cause urine to back up in the urethra
• Catheter to urinate:
• Diabetes
• Advanced age
Treatment
• Fluoroquinolone (or other broad spectrum antibiotic)
• 7-14 days of treatment (depending on severity)
• May treat even longer (2-4 weeks) in males with UTI

20. Recurrent Cystitis
• Recurrent cystitis is usually defined as
three episodes of urinary tract infection
in previous 12 months or two episodes
in previous six months.
• It’s common in young, healthy women .
One study show that 27% of women
developed a second infection within six
months of the first attack.

21. Evaluation and Treatment
• May consider urologic work-up to evaluate for
anatomical abnormality.
• Postcoital antibiotics (taken within two hours of
intercourse) reduce the rate of clinical recurrence
of cystitis as effectively as continuous treatment.
• Self-administered trimethoprim/sulfa-methoxazole or
continuous prophylaxis are effective in preventing
recurrence of cystitis in 95% of the cases
• Cranberry products (juice or capsules) seem to
significantly reduce the recurrence of symptomatic
cystitis.

22. Prostatitis
Diagnosis:
• Typical clinical history (fevers, chills,
dysuria, malaise, myalgias,
pelvic/perineal pain,cloudy urine)
• The finding of an edematous and tender
prostate on physical examination
• Increased PSA
• Urinalysis, urine culture

23. Risk Factors and Treatment
• Being a young or middle-aged man
• Having a past episode of prostatitis
• Cystitis or urethritis
• Having a pelvic trauma, such as injury from cycling or
horseback riding
• Not drinking enough fluids (dehydration)
• Using a urinary catheter
• Having unprotected sexual intercourse
• Having HIV/AIDS
• Being under psychological stress
Treatment:
• Trimethoprim/sulfamethoxazole, fluroquinolone or other
broad spectrum antibiotic
• 4-6 weeks of treatment

24. Complications of Prostatitis
• Bacterial infection of the blood
(bacteremia)
• Epididymitis
• Prostatic abscess
• Abnormalities in semen and infertility
(this can occur with chronic prostatitis).

25. Urethritis
Urethritis is swelling and irritation (inflammation) of the urethra.
Urethritis may be caused by bacteria or a virus. The same bacteria that
cause urinary tract infections (E. coli) and some sexually transmitted
diseases (chlamydia, gonorrhea) can lead to urethritis.
Viral causes of urethritis include herpes simplex virus and
cytomegalovirus.
Other causes include:
Injury
Sensitivity to the chemicals used in spermicides or contraceptive
jellies,creams, or foams
Risks for urethritis include:
• Being a female in the reproductive years
• Being male, ages 20 - 35
• Having many sexual partners
• High-risk sexual behavior (such as anal sex without a condom)
• History of sexually transmitted diseases

26. Presentation
Symptoms
• In men:
 Blood in the urine or semen
 Burning pain while urinating (dysuria)
 Discharge from penis
 Fever (rare)
 Frequent or urgent urination
 Pain with intercourse or ejaculation
• In women:
 Abdominal pain
 Burning pain while urinating
 Fever and chills
 Frequent or urgent urination

27. Treatment
Treatment
(Chlamydia):
Azithromycin – Doxycycline – x 7 days
(Neisseria gonorrhea):
• Ceftriaxone
• Levofloxacin
• Ofloxacin –
• Spectinomycin

28. Pyelonephritis
Infection of the pelvis of kidney
• Symptoms of acute pyelonephritis : short
duration; hours to days
It can cause high fever, pain on passing urine,
and abdominal pain that radiates along the flank
towards the back. There is often associated
vomiting.
• Physical examination may reveal fever and
tenderness at the costovertebral angle on the
affected side.

29. • Most cases of "community-acquired" pyelonephritis
are due to bowel organisms that enter the urinary
tract.
• Common organisms are E. coli (70–80%) and
Enterococcus faecalis.
• Hospital-acquired infections may be due to coliform
bacteria and enterococci, as well as other organisms
uncommon in the community (e.g. Pseudomonas
aeruginosa and various species of Klebsiella).
• Most cases of pyelonephritis start off as lower urinary
tract infections, mainly cystitis and prostatitis.

30. Diagnosis
• Symptoms + U/A (+ve Nitrite and WBCs) are sufficient to diagnose
and are an indication for empirical treatment,
• CBC shows neutrophilia
• Urine culture and antibiotic sensitivity are useful to establish a formal
diagonsis
• KUB if suspected stone
• Where available, a noncontrast CT scan is the diagnostic
modality of choice in the radiographic evaluation of suspected
nephrolithiasis
• Treatment:
2-weeks of Trimethroprim/sulfamethoxazole or fluoroquinolone
Hospitalization and IV antibiotics if patient unable to take oral
medication

31. Complications:
• Perinephric/Renal abscess: suspect in
patient who is not improving on
antibiotic therapy.
• Renal failure
• Sepsis

32. UTI – Diagnostic Evaluation
URINE-ANALYSIS
• Dipstick (leukocyte esterase, nitrites, protein)
• Microscopy (WBCs, RBCs, bacteria, crystals & casts)
URINE-CULTURE
• MSU >105 CFU/ml
• Catheterization > 102 – 104 CFU/ml
• Supra-pubic aspiration > any growth is +ve
BLOOD TESTS
• CBC, ESR, CRP, blood culture
IMAGING
• US, IVU or cystoscopy

33. Habits that might prevent UTI
• Maintain good hydration (especially with
cranberry juice).
• Wipe urethra from front to back to avoid
contamination of the urethra with feces
from the rectum.
• Avoid feminine hygiene sprays and
scented douches.
• Empty bladder immediately before
intercourse.

34. Urine Analysis

35. Types of Sample Collection
There are 3 ways to obtain a urine
specimen:
• Spontaneous voiding
• Urethral catheterization
• Suprapubic bladder aspiration

36. Spontaneous Voiding
• A clean catch - midstream urine sample
is collected after cleaning the external
urethral meatus with soap & water, this
avoids contamination of urine by
contents of urethra or vagina and
therefore its constituents are more likely
to reflect kidney origin.

37. Urethral Catheterization
• The healthcare provider inserts
a foley catheter into the
bladder through the urethra to
collect the urine specimen.
• Required only in special
situations (comatose
patients).
• Has the danger of introducing
microorganisms from urethra
and perineum and causing
urinary tract infection.

38. Suprapubic Bladder Aspiration
• This method is used
when a bedridden
patient cannot be
catheterized or a
sterile specimen is
required. The urine
specimen is collected
by needle aspiration
through the
abdominal wall into
the bladder.

39. Urine Analysis
 MARCOSCOPIC EXAMINATION OF THE URINE
1. Color
2. Clarity
3. odor
 Chemical examination using dipsticks
1. Proteinuria
2. Glycosuria
3. Hematuria
4. Ketones
5. Nitrites
6. Leukocyte esterase test
7. Specific gravity
8. Osmolality
9. pH
 MICROSCOPIC EXAMINATION OF URINE:
1. Red Blood Cells
2. White Blood Cells
3. Epithelial Cells
4. Casts
5. Crystals
6. Bacteria
7. Yeast

40. Diseases Identified with a Urine
Test Strip
• Diseases of the kidneys and the urinary
tract
• Carbohydrate metabolism disorders
(diabetes mellitus)
• Liver diseases and haemolytic disorders

41. Diseases of the kidneys and the
urinary tract
Screening parameters:
UTI
• Leukocytes
• Nitrite
• pH
• Specific gravity
Glomerular/ Tubular diseases
• Protein
• Blood

42. Leukocyte esterase and Nitrite
test
Leukocyte esterase
 Used to detect leucocytes in the urine
 The test is positive if there are more than 5 leucocytes/hpf.
 A negative leukocyte esterase test means that an infection is
unlikely and that, without additional evidence of urinary tract
infection, microscopic exam and/or urine culture need not be
done to rule out significant bacteriuria.
Nitrite test
 Normal urine does not contain nitrites. Urine nitrite test is used
for screening for bacteria
 A positive test indicates presence of more than 10
organisms/ml..

43. pH
• A more acidic pH may be the result of fever, phenylketonuria or
metabolic acidosis.
• Alkaline urine may occur in urinary tract infections, metabolic or
respiratory alkalosis.
• pH of normal urine is between 4.5 and 7.8, but usually it ranges
between 5.0 and 6.0, due to obligatory excretion of acid produced
every day.
• Very alkaline urine is suggestive of infection with a urea splitting
organism. Prolonged storage can lead to overgrowth of urea splitting
organism and falsely cause high urine pH. Rarely alkaline pH may be
due to metabolic alkalosis or acidification defect.
• Low urine pH (<5.0) is most commonly due to metabolic acidosis. Acid
urine may also be associated with ingestion of large amounts of meat.

44. Specific Gravity
• Specific gravity determines the ability of the kidney to
concentrate or dilute urine.
• Specific gravity –depends on both the weight and the number of
particles in solution The normal range is between 1.005 and
1.035..
• Osmolality is dependent only on the number of particles
Osmolality of urine is between 40 to 1200mosm/kg.
• Specific gravity is a convenient and easily measured indicator
of urine osmolality
• To determine specific gravity, urine should be collected after a
period of water deprivation such as an early morning sample
before ingestion of any fluid.

45. Specific Gravity
• Increased: Volume depletion, congestive heart
failure (CHF), adrenal insufficiency, diabetes
mellitus, inappropriate antidiuretic hormone
(ADH), increased proteins (nephrosis)
• If markedly increased (1.040–1.050), suspect
artifact or excretion of radiographic contrast
media.
• Decreased: Diabetes insipidus, pyelonephritis,
glomerulonephritis, water load with normal
renal function

46. Protein
• Most healthy individuals excrete between
30-130 mg/day of protein in urine.
• More than 150 mg/day is defined as
Proteinuria.
• Trace proteinuria = 10mg/dl
1+ proteinuria = 30mg/dl
2+ proteinuria =100mg/dl
3+ proteinuria =300mg/dl
4+ proteinuria = 1gm/ dl

47. Protein
• The urine dipstick is most sensitive to
albumin and is often insensitive to
other proteins. Hence, this may give a
false negative result with
immunoglobulin light chains (Bence-
Jones protein) or microalbuminuria.
• False positive may occur if there is
delay in reading the strip.

48. Protein
• Indication by dipstick of persistent proteinuria
should be quantified by 24-hr urine studies:
• Positive: Pyelonephritis, glomerulonephritis,
Kimmelstiel-Wilson syndrome (diabetes),
nephrotic syndrome, myeloma, postural causes,
preeclampsia, inflammation, and malignancies
of the lower tract, functional causes (fever,
stress, heavy exercise), malignant hypertension,
congestive heart failure

49. Proteinuria can be:
• Transient – occurs commonly especially in children and usually
resolves within a few days often associated with fever, exercise
or stress. In older patients may be due to CHF.
• Intermittent – frequently associated with postural changes.
Commonly occurs in upright position in young adults and rarely
exceeds 1g/day. Resolves spontaneously in about half of
patients and not associated with disease. If normal renal
function evaluate no further.
• Persistent – usually due to glomerular cause with >2g
protein/day of which major component is albumin. Some may
also coexist with haematuria.

50. Blood - Hematuria
RBC: The exact definition of microscopic
hematuria is debated, but is generally
defined as >3 RBC/HPF (40×).

51. Blood
• Positive test indicates
either haematuria,
haemoblobinuria or
myoglobinuria
• False positive readings
most often due to
contamination with
menstrual blood,
vulvar pruritis.

52. Hematuria vs. Hemoglobinuria and
Myoglobinuria
• absence of RBC's on the microscopic examination
Hemoglobin vs. Myoglobin
• Hemoglobin usually is bound and is too large to pass
through the glomerular filter. If the renal threshold is
exceeded, the hemoglobin can pass into the urine.
Myoglobin on the other hand, is not bound and freely
passes through the glomerular filter.
• Free hemoglobin may be present from trauma, from a
transfusion reaction, or from lysis of RBCs (RBCs will lyse
if the pH is <5 or >8).
• There may be myoglobin present because of a crush
injury, burn, or tissue ischemia.

53. Carbohydrate metabolism
disorders
• Glucose - Identified ay Glycosuria
• Ketones - Identified as Ketonuria

54. Glycosuria
• Glycosuria (excess
sugar in urine) generally
means diabetes
mellitus..
• Blood sugar above renal
threshold (10mmol/l or
180mg/dl) will appear in
urine .
• Dipstick will detect
glucose in the urine in
the range of 50 mg/dl to
1000 mg/dl.
• This is specific to
glucose and no other
sugar such as galactose
and fructose.

55. Ketonuria
• acetone, aceotacetic acid, beta-hydroxybutyric acid
• Glomeruli freely filter ketones and the tubules then resorb them
completely. If the tubular resorptive capacity is saturated, then
the ketones are incompletely resorbed, resulting in ketonuria.
• Ketonuria does not signify renal disease, but rather excessive
lipid or defective carbohydrate metabolism.
• Dipstick tests are semiquantitative and only detect acetone and
acetoacetic acid. Reagent strips contain nitroprusside that does
not react with beta-hydroxybutyric acid.
• Ketonuria may be caused by starvation, insulinoma, diabetic
ketoacidosis, persistent hypoglycemia, high fat low carbohydrate
diets, and glycogen storage disease.

56. Diabetic ketoacidosis
• Ketonuria most commonly it is a sign of
impaired insulin function (uncontrolled
diabetes mellitus)
• The finding of ketones in the urine may
signal an urgent medical situation, as
these compounds raise the acidity of
the blood (metabolic ketoacidosis) can
cause coma and even death if
untreated.

57. Liver diseases and haemolytic
disorders
• Urobilinogen - Identified as
Urobilinogenuria
• Bilirubin - Identified as Bilirubinuria

58. Conjugated bilirubin vs.
Unconjugated bilirubin
• Urine normally contains no bilirubin and only
very little urobilinogen.
• Urobilinogen its concentration in urine is
usually <1mg/dl
• Unconjugated bilirubin is water insoluble
and bound to albumin  does not appear in
urine
• conjugated bilirubin is water
solubleappear in urine.

59. Bilirubin and Urobilinogen
- Dipstick It is very sensitive and detects as little
as 0.05 mg/dl of bilirubin resulting in color
change to pink.
- false negative results are obtained if urine is
tested after prolonged exposure, since bilirubin
degenerates with exposure to light.
- False positive results are obtained if there is
contamination with stool or if the temperature
of the reagent strip is elevated.

60. Bilirubin and Urobilinogen
• Low Urobilinogen+Low Bilirubin =
Congenital enzymatic defect/ drugs that acidify
urine, such as ammonium chloride or ascorbic
acid.
• Low Urobilinogen+High bilirubin = biliary
obstruction
• High Urobilinogen+High bilirubin =
Hemolytic Anemia

61. Thank You! 